Complete Text (Part 18)

be fatty degenerated. In spontaneous rupture, on the other hand, the rent is often THE HEART. 125 very small, and its canal so irregular that a sound can be passed through it with difficulty ; the adjoining tissue is infil- trated with blood and the muscular tissue fatty degenerated. (5.) Hypertrophy may be confined to either side of the heart alone, or may affect both sides, and it is usually not diffi- cult to discover its mechanical cause. For instance, in insuf- ficiency and stenosis of the aortic valves, both ventricles are generally hypertrophied ; the left directly in consequence of the valvular lesion, the right secondarily from stasis of the blood in the pulmonary circuit, and the increased de- mand which is thus made upon it. Hypertrophy of the right ventricle may depend either on changes in the heart itself (stenosis and insufficiency of the mitral valve) or on changes in the lungs. If extensive destruction of the pul- monary capillaries has taken place, — from phthisis, for in- stance,— or if in any other way the circulation has been appreciably impeded, the explanation of the hypertrophy is easy ; we are, however, not yet able to give a satisfactory explanation for the fact that a higher degree of hypertro- phy is often associated with chronic bronchial catarrh than can be accounted for by the amount of emphysema present, or by other changes in the pulmonary parenchyma. Fatty degeneration confined to the right ventricle is very common in all these cases. The conditions which may give rise to hypertrophy of the left ventricle are much more numerous, and cannot be treated in detail here. We must, however, mention the interesting connection which exists between hy- pertrophy of the left ventricle and atrophy of the kidneys. Many recent writers have endeavored to connect hypertro- phy of the left ventricle and of the whole heart, without dis- coverable anatomical cause, with overwork — idiopathic car- diac hypertrophy. This condition is often met with in sol- diers, etc. (c.) Inflammatory changes may be divided into paren- chymatous and interstitial, the former involving the true muscular, the latter the intermuscular fibrous tissue, though it never occurs independently of the former. 126 DIAGNOSIS IN PATHOLOGICAL ANATOMY. 1. Parenchymatous changes may be either general or par- tial. The general form is found in almost all infectious dis- eases, and is characterized in its earlier stages by a grayish- red opacity of the flaccid muscular walls, while later fatty changes arise. The muscular fibres in the first stage, when examined microscopically, contain granules resembling those of fat but really of an albuminous nature, as is shown by their disappearance on the addition of acetic acid or the dilute alkalies. The partial form is a result of a plugging of the branches of the coronary arteries by septic emboli, as in puerperal fever, pyaemia, ulcerative endocarditis, glanders, etc. ; it is manifested by the presence of small abscesses as large as or somewhat larger than the head of a pin, which are generally multiple, with a red areola, and contain pus cells and a large amount of fatty degenerated muscular tissue (the second stage of parenchymatous inflammation). This affection is the precursor, as it were, of — 2. Interstitial inflammation, since the pus cells are to be regarded as evidences of acute, purulent, interstitial inflam- mation (interstitial suppurative myocarditis'). The malig- nant character of the emboli is explained by the usual pres- ence of collections of micrococci within them, such as are also to be found at the point from which the embolus was detached. Chronic interstitial inflammation is more common than the acute form, and may also be limited to small areas. It is attended with the formation of fibrous tissue, — chronic fibrous interstitial myocarditis^ — which has replaced the muscular fibres at the surface of the apices of the papillary muscles, or at the surface of the trabecule, or else appears in the midst of the muscular wall in the form of dense gray streaks. In the latter case the changes are best brought to view by a horizontal cut through the muscular substance, for instance, through the triangular portion of the wall which results from the opening made into the aorta. The microscope reveals a conversion of the interstitial into cica- tricial tissue and an atrophy of the intermediate muscular THE HEART. 127 fibres. There is a remarkable condition known as chronic saccular aneurism of the heart, the chief seat of which is the apex of the left ventricle. It depends on fibrous myo- and endocarditis, which may so diminish the thickness of the cardiac wall that the latter gradually yields to the pressure of the blood at this point, and may finally be ruptured. (c?.) Among tumors we will first mention gummata, which sometimes are found in the form of large yellow nodules. Syphilis may also give rise to fibrous myocarditis, but, as in other organs, the true nature of this change can be recog- nized with certainty only when gummy formations are pres- ent at the same time. Tubercles occur occasionally in this situation in general miliary tuberculosis, but very rarely in the form of cheesy masses ; these are always here the result of syphilis. S^ar- coma, and particularly myxosarcoma, may be primary in the heart ; so also myoma, with stellate, transversely striated muscle cells, in new-born children. Secondary nodules of general carcinoma, sarcoma, melanoma, etc., may also occur, and the latter may give rise to embolism of the pulmonary arteries. (e.) The entozoa are rarely formed in the heart. Tri- chinae are never found, but both cysticerci and echinococci have been known to occur. (/.) Among congenital malformations we will mention persistent patency of the foramen ovale, and deficiencies of varying size in the ventricular septum. The former is rela- tively common, but can be easily overlooked, as the com- munication between the auricles is not always direct, but may be formed by an oblique canal or fissure resulting from defective union between the membranes which are formed on either side and normally close the opening. Supernumerary muscular and tendinous bands are often met with, espe- cially between the anterior wall of the left ventricle and the septum. {ß.) Of the Endocardium. The last important part of the heart, the endocardium, is 128 DIAGNOSIS IN PATHOLOGICAL ANATOMY. ordinarily nowhere separated from the myocardium by fatty tissue, but in very fat persons, as well as in those laboring under obesity of the heart, a thin layer of fat is sometimes deposited in this place. Such a layer is very sharply defined in a transverse section, and its glistening fat cells are suffi- ciently characteristic. Slight effusions of florid blood are also occasionally found in this situation. The endocardium is very often stained red by the color- ing matter of the blood, and this redness, apart from its diffuse and indistinct character, cannot be attributed to in- flammation on account of the low degree of vascularity of the membrane. Pathological conditions are found with far greater fre- quency in the valvular than in the parietal endocardium. (a.) The parietal endocardium is often the seat of cir- cumscribed fibrous thickening (^chronic fibrous parietal endo- carditis'), especially in connection with superficial fibrous myocarditis. The membrane may also be the seat of general thickening with circumscribed verrucous and ulcerative inflam- mation (verrucous and ulcerative parietal endocarditis), the latter almost always an extension of similar changes in the valves ; the left ventricle is chiefly affected by this condition. Local ulceration of the parietal endocardium, by permitting the direct action of the blood current upon the muscular wall and the pericardium, may give rise to an aneurismal dilata- tion of a portion of the wall — acute aneurism of the heart. (b.) It is a well-known fact that valvular disease which has arisen during life is generally seated in the left heart, very rarely in the pulmonary, and only exceptionally in the tricuspid valve ; while during foetal life the valves of the right heart are much more liable to suffer than those of the left. The commonest pathological condition, generally associated with atheroma of the aorta, is not an inflamma- tory but a simple regressive metamorphosis, and appears as irregularly shaped yellow spots of varying size, which are due to fatty degeneration of the connective tissue corpuscles of the part, and do not interfere in any way with the func- tion of the valve. THE HEART. 129 The most important pathological conditions are those which are due to inflammation (valvular endocarditis)^ and may be divided into two classes, acute and chronic. The line of closure of the valves is the favorite seat of both these classes of changes ; this lies at a little distance from the free borders of the curtains of the mitral, and in the segments of the aortic valves describes two curved lines which inter- sect the free borders at their middle points, the corpora arantii. Occasionally the changes are limited to the line of junction of the valves with the parietes (basilar valvular endocarditis), but they more commonly occur in both these lines at the same time. They first make their appearance, moreover, on that side of the valve which is turned toward the blood current — the ventricular surface of the aortic valves, the auricular surface of the mitral. We will take up the chronic form first on account of its greater frequency. This may be a simple fibrous thicken- ing of the valve curtains (chronic fibrous endocarditis), with which more or less retraction is apt to be associated ; if the mitral valve be thus affected,, the process almost always in- volves some or all of the chordse tendinese which are thick- ened and retracted. Fusion may also take place between the contiguous free borders of the segments, beginning at their extremities ; this condition occurs chiefly in the aortic valve, and gives rise to stenosis and insufficiency. Small papillary elevations sometimes occur in the valves, either in conjunction with or independently of these fibrous changes, and may become largely calcified, even of a stony hardness. The acute form may be either primary or the recurrence of a preexistent endocarditis. It, too, may be attended by the formation of soft papillary elevations on the line of closure of the valves, resembling a cock's comb, of a white or gray color and somewhat translucent ; these are shown by the microscope to consist of papillary connective tissue, which may perhaps be derived from the small projections which often are normally present in this situation. Or else we may find on the valves bodies varying in size between that of a 130 DIAGNOSIS IN PATHOLOGICAL ANATOMY. cherry-stone and that of a hazel-nut, soft, gray, grayish-red, or grayish-yellow in color, and, as a rule, easily separable from their attachments ; the microscope and acetic acid show these to consist of fibrins derived from the blood. The sub- jacent surface of the valve is not smooth as in the pap- illary variety, but it is ulcerated and often increased in thickness Qalcerative endocarditis). In the papillary variety the remaining portions of the curtains may be quite intact, while in the ulcerative form they are apt to be swollen and of a dirty yellowish hue. This form occurs chiefly in puerperal fever, pyaemia, etc., and has been called ma- lignant or diphtheritic endocarditis^ from the fact that the microscope reveals, in the tissue of the valves as well as in the thrombi, the presence of numerous colonies of mi- crococci, such as are also found within the multiple emboli which are so frequent in these cases. The organisms may be easily demonstrated by boiling the specimen in absolute alcohol and ether, and then examining it in glacial acetic acid. This form is more apt to be recurrent than pri- mary, and the ulceration may extend from its origin in the line of closure of the valves and involve the parietal en- docardium. There are, however, cases of acute ulcerative endocarditis which do not possess this malignant character ; ulceration in rare instances, for example, may be set up me- chanically by the repeated impinging of a cretified nodule on the aortic valve against the mitral curtain, the ventricular layer of which may be thus completely destroyed while the auricular layer is dilated in the form of an aneurism (acute valvular aneurism'). This dilated portion may finally be- come perforated and the ulceration extend somewhat on the other side. (It is scarcely necessary to mention the fact that perforation of the valves may also take place in the malignant form.) Chronic valvular aneurism is found only in the left ventricle, and consists in a sacculation of all the layers of the valve, the convexity being always opposed to the blood-cur- rent — in the aortic valve toward the ventricle, in the mitral toward the auricle. The formation of thrombi may then give THE HEART. 131 rise to secondary changes, and sudden death result from embo- lism of the carotid ; or else rupture may take place, and in- sufficiency be the result. Similar aneurismal dilatation occurs also in the upper part of the interventricular wall (septum fibrosum) and in the sinuses of Valsalva, particularly the right. Both papillary and ulcerative inflammation occur also on the chordse tendineas, which may be completely separated by the latter form, and thus incomplete valvular closure be brought about. There is a peculiar appearance which is sometimes met with in young children on the line of closure of the valves, called hcematoma of the valves ; it consists in the presence of a number of small prominences, which sometimes occupy the whole circumference of the line of closure, and thus form a circle — the apices of which are dilated and contain small collections of blood. Fenestrated valves., semilunar valves with one or more defects between the line of closure and the free border, still retain their function unimpaired, and hence possess no special clinical interest. So also the oc- casional presence of four segments in the semilunar valves. In cases of valvular lesion a deposit of fibrine is often formed on the intact ventricular wall as well as on the diseased valves (parietal thrombosis'). Mechanical interference with the circulation may also give rise to this condition without the intervention of valvular lesion (marantic thrombosis). Hence it is especially liable to occur in the right heart, at the apex, between the trabeculse and in the auricles, the points at which the circulation is least rapid. Such thrombi may be small and scarcely project above the surface of the trabeculas, or they may be as large as or even larger than a cherry, and project boldly into the cavity Qhe globular veg- etations of Laennec) ; in the latter case they are usually firm and gray, or grayish-red at the periphery, and soft, reddish- gray, yellow, or brown at the centre. They are not to be confounded with those firm and tough grayish-yellow masses of fibrine which are formed just before death, and can always be disentangled from the trabeculse with comparative ease. 132 DIAGNOSIS IN PATHOLOGICAL ANATOMY. (y.) The Commencement of the Ao7'ta and the Coronary Arteries. The commencement of the aorta and the coronary arteries should be examined in connection with the heart. The in- tima of these vessels may present conditions similar to those of the valves in chronic endocarditis. Yellow irregular spots are due to fatty changes in the cells of the intima ; chronic inflammation of the intima (chronic deforming endarteritis) leads to local thickening or sclerosis, with which is associated cellular fatty degeneration and calcification. It is precisely this calcification of the patches of sclerosis within the coro- nary arteries which often causes considerable diminution in their calibre, and thus impairs the nutrition of the myo- cardium. The fatty change in the cells of the sclerosed patches may also involve the connective tissue, so that finally a cavity is formed containing a mixture of fat and Choles- terine (atheromatous abscess), which may rupture inwards, and thus form an atheromatous ulcer. On and about this, fibrine may then be deposited, and a place of origin formed for embolism of other organs or parts. These changes in the intima are often associated with dilatation of the wall — aneurism. This condition, as well as a diminished calibre or hypoplasia, so often associated with chlorosis, etc., will be described in another place. Under congenital changes may be mentioned the tolerably frequent variations in the origin of the coronary arteries, which are sometimes given off high up on the aortic wall, instead of in the sinuses of Valsalva, or both may communi- cate with the aorta through the same opening. The ductus arteriosus sometimes remains open in adult life. 8. THE LUNGS. To examine the lungs thoroughly they must first be re- moved from the thorax, but this must be done with great care, that the pulmonary tissue may be neither lacerated nor crushed. If extensive or old adhesions are present they are not to be torn through, but the costal pleura is also to be TEE LUNGS. 133 removed at these places according to the following method. A longitudinal incision is to be made in the costal pleura, and a finger of the right hand worked behind the lower edge of the cut along an intercostal space ; by a lateral move- ment of the finger and simultaneous traction inwards, space can generally be made for the hand, with the aid of which the detachment may be completed. In order to protect the back of the hand from being injured by the costal cartilages, which are very apt to be calcified in such cases, the external integ- ument should be folded over the cut ends, while the other hand draws them forcibly outwards. After the surface of the lungs has been freed from its attachments, the root of the left lung should be included between